美國呼吸衰竭治療方案英文版

RESPIRATORYFAILURE

MANAGEMENTDr.Sivasubramanian.T.A.DEPARTMENTOFANAESTHESIOLOGYIBRIREGIONALREFERRALHOSPITALRESPIRATORYCAREAmbientPressureTherapyPositivePressureTherapyAMBIENTPRESSURETHERAPYOxygenTherapyHumidityTherapyBronchialHygeineTherapyPharmacotherapyOXYGENTHERAPYOxygenDelivery=O2ContentxCardiacOutputO2Content=HbxSaO2x1.34+PaO2x0.003OXYGENTHERAPYAimstoimprovePaO2byincreasingFiO2EffectiveFiO2-0.24-0.50FiO2>0.50notindicatedOXYGENTHERAPYDeliveredbyVariablePerformance/LowFlowSystemFixedPerformance/HighFlowSystemLOWFLOWSYSTEMLOWFLOWSYSTEMFiO2dependsonSizeofO2ReservoirO2FlowRateBreathingPatternLOWFLOWSYSTEMSimplicityPatientComfortEconomicalInaccurate/NotdependablePERFORMANCEO2FlowRate(L/M)FiO2Nasalcannula20.2840.3660.44OxygenMask5-60.406-70.507-80.60Maskwithbag60.6080.8010>0.80HIGHFLOWSYSTEM3-4timesMinuteVolumeAccurateoverarangeofMinuteVolumeFiO20.24-0.40HigherFiO2bylarge-volumenebulisersHIGHFLOWSYSTEMHUMIDITYTHERAPYAIR50%HUMIDIFIED20oC<10mg/LALVEOLI100%HUMIDIFIED37oC44mg/LNoseHUMIDITYTHERAPYDeliveredbyHumidifiersNebulisersHMEseg.ThermoventHUMIDIFIERSWaterbathsSupplyheated,humidifiedair100%saturatedPreventwaterlossfromlungsCannotsupplyadditionalwaterNEBULISERSAerosolmistsParticlesize2-5mSupply150-1500mg/LwaterUsefulforliquefyingdriedsecretionsDelivermedicationsNEBULISERSTypes:VenturiUltrasoundULTRASONICNEBULISERWaterbrokenupbyresonatorUpto6mlin1min.Particlesize~2mCancausewateroverloadMainlyusedformedicationHMEHeatandMoistureexchangerAlsocalled‘Artificialnose’Efficiency70%↑ResistanceBacteriostatic?BRONCHIALHYGEINETHERAPYRetainedsecretionscancauseAtelectasisPneumoniaV/QmismatchHypoxaemiaBRONCHIALHYGEINETHERAPYProphylactic:ChestPhysiotherapy-Posturaldrainage,Chestpercussion,CoughassistIncentiveSpirometryAerosolBRONCHIALHYGEINETHERAPYTherapeutic:EndotrachealsuctioningFiberopticBronchoscopyChestphysiotherapyENDOTRACHEALSUCTIONHarmfuleffects:TraumaAlveolarcollapse↑VagalactivityPrecautions:PreoxygenateCathetersizeTimeObligatoryhighinflationFIBEROPTICBRONCHOSCOPYAfterallothermeanshavefailedIrrigationSuctionForreexpandingcollapsedsegmentsCHESTPHYSIOTHERAPYMostimportantPosturaldrainageChestPercussionandVibrationIncentiveSpirometryPHARMACOTHERAPYClassification:DrugscausingbronchodilatationDrugsreducingmucosaloedemaDrugsthatliquifymucusBROCHODILATORS2StimulantsTheophyllineAnticholinergicsBETASTIMULANTSUsefulasAerosolorMDIBronchialsmoothmusclerelaxantSalbutamol,Metaproterenol,RacemicEpinephrineSideeffects:Tachcardia,Tremors,Hypokalaemia,HyperglycaemiaBETASTIMULANTS

Dosage:DrugNebulisedMDIFrequencySalbutamol2.5-5.0mg90

g/puff(2puffs)4-6HrlyMetaproterenol5%0.3ml0.65mg/puff4-6HrlyRacemicEpinephrine2.25%0.5ml-HrlyTHEOPHYLLINENotusuallyrecommendedLesseffectiveMoresideeffectsNosignificantreliefinAcutestatesTHEOPHYLLINEPhosphodiesteraseinhibitorAminophylline-Theophylline+EthylenediamineDesiredTherapeuticlevel:10mg/LToxicity:>20mg/LTHEOPHYLLINELoadingdose:NopriorRx6mg/kgOngoingRxTD-TP/0.6Rateofinfusion<0.2mg/kg/hrTHEOPHYLLINEContinuousRate:Standard0.5mg/kg/hrLowcardiacoutput0.2mg/kg/hrSmokers0.8mg/kg/hrANTICHOLINERGICIpratropiumInhibitsvagallymediatedreflexesAdjuvanttosympathomimeticsIPRATROPIUMBROMIDENebulised-0.5mg/DoseMDI-18g/puff(2puffs)4thhrlyCanbemixedwithstimulantsTakes20min.toactEfficacydoubtfulCORTICOSTEROIDS↓Inflammation&OedemaofsmallairwaysNoteffectiveinAc.StatesUsefulinlaterstagesTake6-8hrs.toactAerosol/IVCORTICOSTEROIDSAerosolDrugNebulisedMDIBeclomethasone6hrly-42

g/puff(2puffs)Dexamethasone6hrly1mg-Triamcinalonetid-100

g/puff(2puffs)CORTICOSTEROIDSIntravenousHydrocortisone:2mg/kgStatand2mg/kg4hrlyMethylprednisolone:80-125mgStatand80mg6hrlyMUCOKINETICTHERAPYBlandaerosolsN-acetylcysteine(NAC)BLANDAEROSOLSLiquifythicktenaceoussecretionsSaline-Hyper-,Hypo-orIsotonicDistilledwaterHypertonicinducescough

N-ACETYLCYSTEINE10%and20%solutionsAerosolDirectinstillationintracheaDisagreeabletaste-nausea&vomitingIrritant-Cough&BronchospasmHypertonic-BronchorrhoeaPOSITIVEPRESSURETHERAPYPositive